Low, But Rising PSA--Wait for Imaging or Act Now?

https://www.hopkinsmedicine.org/news/articles/2023/12/salvage-radiation-after-prostatectomy-watch-the-psa
I think Surfer mixed up her percentages🤔 in translation - it’s more like 60% success and even a bit higher with the addition of ADT.
Dr Kwon says that about 35% of SRT fails, which is why he likes to shoot only what he sees…which makes absolutely NO SENSE when you consider SRT is almost 65% successful.
Phil

@heavyphil

Hi Phil - you are absolutely right , that is what studies show 👍.

I was referring to what Dr K. said in that video trying to reiterate his point of view and saying that even if HIS percents are "correct" that even THAN early sRT makes sense. According to him about 30 % would not have any benefit , and in earlier part he said that about 30% do have recurrence in pelvic area so it leaves about 30% with "some" benefit I guess lol - one should ask him about that. I was trying to follow his reasoning to make a point that even IF it is just 30 % chance it would be a great chance. Once cancer leaves that area, there is no chance.

I personally have no intention to follow something not proven in any randomized study. 😊

Thanks to all for the input; it is truly appreciated. And sorry to our vets who took home a nasty surprise while serving our country in VN. I waited to post until I had some new information.
My stats are in the original post but suffice it to say I am 72, had RALP on 9/22/25 and my cancer is aggressive. PSA results post RALP: 12/30/25: < .1; 4/5/26: 0.171; 5/4/26: 0.180. So, like @suftohealth88's husband, I have BCR (he and I have very similar stories; see "uPSA today 0.13 : (((" thread also with posts today).
I saw Dr. Nagur in MSK on 5/6. He very quickly dismissed the Dr. Kwon approach of waiting till 0.2 PSA to get a PMSA PET scan by saying "why would you wait for metastases?" He also said getting the scan now was "standard of care."
He knew I was going to be treated in Johns Hopkins (JH)/Sibley so he seemed reluctant to offer much as to his opinion on proper treatment. In fact at one point I had to say "I came to NY from DC because I want your opinion." He recommended 6 months of ORGOVYX and radiation, with exact details of radiation to be determined by JH. I was expecting much more aggressive treatment and reminded him I have IDC and Cribriform, but he didn't change his recommendation. I was so surprised and happy with that outcome that I didn't press him more on it, as I should have. Honestly, it seemed he didn't want to get into much detail because my treatment was in DC, or he just wanted to wait for the results of the tests he recommended: PSMA PET, Decipher (on tissue from the prostate itself, not the biopsy core, as before) and AlteraAI.
I have an appointment with Dr. Greco (RO) on 5/14 and with Dr. Paller (MO) on 6/16 (thanks for the recommendations for her). I have already asked Dr. Greco to order the PMSA PET but haven't heard back yet. My PSA could be 0.2 by the time it happens, anyway, unfortunately.
@surftohealth88, Happy Mothers Day (please excuse this if you and your husband don't have kids). In any event, I hope you and your husband have a great day.
I am on my way back east from SFO and I will be mountain biking in Moab tomorrow and Tuesday along the way.

@bikeman1
You hear what Doctor Kwon And Doctor Scholz Say at PCRI conferences. They like to wait for the metastasis to show up rather than treat them with salvage radiation.

Then there’s the facts about what happens if somebody waits when they have an aggressive case of prostate cancer. It’s not a pretty picture. My notes about it are below the link,

Life expectancy for prostate cancer patients that ignore treatment
https://www.urotoday.com/recent-abstracts/urologic-oncology/prostate-cancer/168250-natural-history-of-untreated-prostate-cancer-a-comprehensive-review-of-long-term-progression-patterns-and-survival-outcomes-beyond-the-abstract.html
Grade Group 1 (Gleason 6) disease showed metastatic progression rates below 5% over 15–20 years and prostate cancer-specific mortality under 5% at two decades. These are the patients for whom active surveillance was designed, and this review provides robust quantitative backing for that approach. Conversely, Grade Groups 4–5 (Gleason 8–10) were uniformly lethal in conservatively managed cohorts: median time to metastasis was 3–5 years for Gleason 8 and just 1–3 years for Gleason 9–10, underscoring the urgency of early intervention for these men.

The intermediate grades deserve particular attention. The distinction between Gleason 3+4 and 4+3—both classified as "Grade Group 2–3" and both often lumped together as "intermediate risk"—carries meaningful clinical weight. Our synthesis found roughly 2–3 fold differences in 15-year progression rates (35% vs. 55%) and hazard ratios for cancer-specific death of 2.1–3.2 between these two patterns. Clinicians and patients should not treat these as equivalent.

@clevelandguy The rational is that when you are treating at these very low PSA levels you are treating micro metastatic disease. The beds and pelvis area are likely locales. The risk is that not all or any of the micromets is there and you have been treated unnecessarily. However, the rest of the body is also being treated with ADT. That is for the whole body not just the bed and pelvis and studies show it provides additional benefits to delay or avoid mets. So yes it would be great to wait and see it but the numbers discussed above do not support that approach. They support treat early. Also seeing something to treat is not a panacea as there could also be other sites of not visible micromets. There is no easy answer but as someone with adverse features I want to get treated.

Thats your choice, I don’t think I would radiate my pelvic area unless I know there is cancer to kill. There is a good possibility of damaging the bladder and colon.

Dave 3+4

@clevelandguy
Salvage radiation is the standard of care. It very seldom causes much damage to the bladder or rectum. What it does cause usually goes away after a short period of time. I had salvage radiation 12 years ago and had no side effects at all.

If nothing can be seen in the PET scan, the most likely place for micro metastasis is in the prostate bed or the lymph nodes in that area. The American Society of clinical oncology and many other groups recommend salvage radiation in that case.

You haven’t been around here very long, you will find out that a large number of people that have had a prostatectomy end up needing salvage radiation. It is very common. And works very well for most people..

You should look at the links above, that I provided, about what benefits salvage radiation provides for people that have serious cases of prostate cancer.

@jeffmarc
Thats your choice, I don’t think I would radiate my pelvic area unless I know there is cancer to kill. There is a good possibility of damaging the bladder and colon. This is from Sloan Kettering:
“Radiation therapy can cause permanent urinary and bowel changes. Many people don’t notice any changes or have any symptoms. However, some people have late side effects.
Late side effects may be similar to the ones you had during treatment. There’s a very small chance you may develop other side effects. For example:
The opening of your bladder may become narrower.
You may lose your ability to control your bladder.
You may have blood in your urine.
You may have bleeding from your rectum.
Your rectum may be injured.
These side effects are rare. They may come and go over time or be persistent and chronic. Your healthcare team will help you manage them.” That’s great you did not have any long term problems but the radiation affects people differently. Just because you did not have any problems does not mean the next person will also not have any problems. Yes I am new to this site but have been on the American Cancer Society site for 11 yrs. I don’t know what you mean a large number will need extra radiation but on the ACS site many who posted that had surgery did not need extra radiation in the prostate bed. To each his own but 65% odds of the cancer not being there and let’s just radiate it anyway is iffy in my book. I will wait for it to show up in PET scan then spot radiate it. My body, my choice.

Dave 3+4

@jeffmarc Presumably Mayo's new trial will answer this specific question but I just see so many questions. Presumably everyone agrees that the SOC is to treat as early as possible for a biological recurrence after prostatectomy. Depending on definitions that would be at a .1 PSA which is then confirmed by a second PSA or just.2. The prevailing practice then is that it is best to treat at .25 or below and otherwise best if below .5. So what has changed? The only variable is that PET PSMA has become standard. And the entire question relates only to those that have biologically recurred but the Pet PSMA is negative. A very narrow cohort and question. Mayo is asserting correctly that we have many prostate cancers that biologically recurred after surgery but never metastasize. That also has been known. But now in the context of PSMA Pet they are having a trial to determine if we could avoid a lot of unnecessary treatment if we delay treatment and use PSMA to find the hotspot as PDA rises. This is where I get hung up. Obviously if PET PSMA had sensitivity where everything showed at .1 or .2 the trial would make perfect sense, but that simply isn't true. Both Surf's husband and I already see how fast PSA rises in some cases. So even intentionally pursuing treatment results in delayed treatment with fast doubling time cancer. What would our PSA's be at the time of treatment if we waited for positive imaging? How could that be beneficial given what we know about the importance of early treatment? I just see a lot of people like me that would easily blow past by .5 and up to 1 and then IF the psma imaging revealed the source(s) you would get treatment? Anyway, I know I am preaching to the choir it is just hard to see the underlying rational.

@dhasper
I think it’s a choice between you and your doctor team based on your specific situation. Take into account what the overall medical experts say, what your doctor team says and what you want to do. If all agree to radiate before it shows on a PET scan go for it. We are kinda lucky with Pca that the PSA test can tell us before it’s picked up on a PET scan that something is going on. The choice on when to treat it is the tricky part.

Dave 3+4